Adherence Key to Effective Management of Schizophrenia

Author: Yvette C. Terrie, BSPharm, RPh

Ms. Terrie is a clinical pharmacy
writer based in Haymarket, Virginia.

Schizophrenia is a chronic, complex,
and challenging disorder
that requires long-term treatment,
affecting approximately 1% of the
world population—an estimated 2.5 million
individuals in the United States—and
rates of incidence are comparable among
both men and women.1-4 In men, the
onset of schizophrenia is typically during
the teen years or early 20s; and in
women,the onset is typically in the 20s or
early 30s. Onset in childhood is rare; however,
early adolescent or late-life onset
(referred to as paraphrenia) may occur.1

Alcohol abuse, drug abuse, social anxiety,
and depression are common among
patients with schizophrenia, and an estimated
10% of schizophrenic patients
commit suicide.4-6 Addiction to nicotine is
the most common form of substance
abuse in patients with schizophrenia; this
population is addicted at 3 times the rate
of the general population.4

Schizophrenia may exist alone or in
conjunction with other psychiatric or
medical conditions. In order to effectively
counsel patients affected by schizophrenia,
pharmacists should have some
insight into this condition and the treatment
options available for the management
of schizophrenia.

Residual schizophrenia—more prominent
symptoms, followed by a prolonged
period of mild negative symptoms1-4

Causes

According to the American Psychiatric
Association (APA), although the exact
cause of schizophrenia is unknown,
research suggests that biological and
environmental factors play a role in both
the onset and course of schizophrenia.7
In addition, scientists know that some
hereditary basis or genetic predisposition
for the disease exists.1,4,6,7 Statistics
indicate that, although an estimated 1%
of the population has schizophrenia, it is
seen in 10% of individuals that have a
first-degree relative with schizophrenia.4

Signs and Symptoms

Since no one symptom positively identifies
schizophrenia, patients may exhibit
various types and degrees of symptoms,
which can be classified into 3 general
categories: positive symptoms (eg, delusions,
hallucinations, unusual perceptions
or thoughts), negative symptoms
(eg, loss or decrease in ability to initiate
plans, speak, or express emotion), and
cognitive symptoms (problems with
attention, sustaining attention, certain
type of memory, and ability to plan and
organize things).1,2,4,6,7

Effective Patient Counseling

Because schizophrenia is a long-term
and recurrent illness, patient adherence
to therapy is essential. At the annual APA
meeting in May 2007, results were presented
from the National Adherence
Initiative in Schizophrenia Survey, which
involved 13,000 patients with schizophrenia
and used a new screening tool.
The survey indicated that the most common
reasons for failing to take medication
prescribed for schizophrenia by 2
out of 3 patients included poor insight
(74%), forgetting to take medication
(68%), and previous discontinuation of
medication (67%).6 The screening tool
identified 8 factors that can be associated
with nonadherence: (1) poor insight
about illness; (2) forgetting medication;
(3) stigma associated with taking medication;
(4) presence of psychotic symptoms;
(5) previous discontinuation of
medication; (6) stigma about hospitalization;
(7) drug/alcohol abuse; and (8) experiencing
adverse effects from prescribed
medication.8

Treatment

Although no cure exists for schizophrenia,
a variety of treatment options
are available for its management, including
pharmacologic therapy, psychotherapy,
rehabilitation, and family and community
support.1,2,4 The main goals of
therapy are the reduction or exacerbation
of symptoms and to minimize the
incidence of relapse.5 An early diagnosis
and initiation of a treatment plan are very
important and may prevent or delay the
severity of this condition or the need to
consider augmentation therapy.5,9

The 2 general classes of drugs available
for treating this condition are conventional
antipsychotics (eg, chlorpromazine
[Thorzine], thioridazine [Mellaril],
and haloperidol [Haldol]) and atypical
antipsychotics (eg, clozapine [Clozaril],
risperidone [Risperdal], olanzapine [Zyprexa],
quetiapine [Seroquel], ziprasidone
[Geodon], and aripiprazole [Abilify]),
which are available in a variety of dosage
forms, such as tablets, oral-disintegrating
tablets, liquids, and short- and long-acting
intramuscular injections. Switching to
the use of injectable long-acting antipsychotics
via intramuscular administration
for certain patients (ie, patients with
indifference or denial of illness who cannot
reliably take daily oral medications)
may be necessary and also may produce
better results in efficacy, tolerability, and
relapse prevention.1,5

Conventional antipsychotics can control
positive symptoms such as delusions
and hallucinations. Adverse effects associated
with the use of conventional
antipsychotics include sedation, dystonia,
tremors, elevated prolactin levels,
and weight gain. These agents also may
cause akathisia (motor restlessness),
which may result in patient nonadherence,
as well as tardive dyskinesia.1

Atypical antipsychotics were first
introduced in the 1990s and are used to
manage both positive and negative
symptoms associated with schizophrenia.
These agents are less likely to cause
extrapyramidal effects, may have a lower
incidence of tardive dyskinesia, and produce
little or no elevation of prolactin levels.
1 According to a joint panel of the
American Diabetes Association, the APA,
the American Association of Clinical
Endocrinologists, and the North American
Association for the Study of Obesity,
the use of atypical antipsychotics is associated
with incidence of weight gain.10
Studies also show an association between
atypical antipsychotic use and the
development of prediabetes, diabetes,
and elevated blood lipid levels.10

The panel recommends baseline
screening of personal and family history
of obesity, diabetes, and dyslipidemia,
fasting glucose, and fasting lipid profile
prior to initiating therapy and routine
monitoring while on therapy.5,10 It also
concluded that the atypical antipsychotics
differ in their risk profiles and that
some agents, although effective treatment
options, raise a greater risk of
weight gain, diabetes, and lipid disorders
than other agents.10

Clozapine and olanzapine produce the
greatest weight gain; quetiapine and
risperidone produce intermediate weight
gain; ziprasidone and aripiprazole produce
the least weight gain.10,11 Results
from a study published in the January 9,
2008, issue of the Journal of the American
Medical Association report that metformin
and lifestyle interventions, alone
or in combination, were effective for
antipsychotic-induced weight gain and
abnormalities in insulin sensitivity.11,12

Although the FDA had not previously
approved any medication to treat schizophrenia
in adolescents, the FDA approved
risperidone in August 2007 and approved
aripiprazole in November 2007 for the
treatment of schizophrenia in adolescents
aged 13 to 17.13,14 Also in November 2007,
quetiapine extended-release tablets received
an expanded indication and were
FDA approved for maintenance treatment
of schizophrenia in adults.15

The Pharmacist's Role

As one of the most accessible health
care professionals, pharmacists can positively
impact patient outcomes by stressing
the importance of medication adherence,
as well as encouraging patients to
maintain routine visits with their primary
health care provider. When counseling
patients, pharmacists should remind
them about the benefits of medication
therapy and educate them of the potential
adverse effects of the selected medication.

For more information on schizophrenia,
please visit the following
Web sites:

National Institute of Mental Health,
National Institutes of Health:www.nimh.nih.gov

Mental Health America (formerly
known as the National Mental
Health Association):www.nmha.org

Patients should be reminded to not discontinue
any of their medication unless
directed by their physician, report any
side effects to their primary health care
provider, and to not use any other medications,
including nonprescription drugs,
vitamins, and herbal medications, without
seeking advice from their primary health
care provider. It also is important for
patients to be advised against the use of
alcohol. Because quitting smoking may
be difficult for patients with schizophrenia,
smoking cessation strategies such as
nicotine replacement methods may be
recommended. If patients do not stop
smoking or start smoking, physicians
should monitor their response to antipsychotic
therapy.4

Successful therapy starts when
patients have a thorough understanding
of their therapy and the importance of
therapy adherence. Pharmacists can be
instrumental in identifying possible contraindications
or drug interactions for this
patient population and recommending
various strategies that patients can use
to increase adherence to their therapy,
such as the use of medication reminder
devices, using automated-refill features
to ensure prescriptions are filled on time,
and using 1 pharmacy for all prescriptions.
Most importantly, pharmacists can
assist patients with schizophrenia by
showing empathy, providing encouragement
and support, and reminding them
that adhering to their therapy is the
most effective tool in managing schizophrenia.